CLINICAL OUTCOME & MORPHOMETRY OVER 2 & 5 YEARS -
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1 CLINICAL OUTCOME & MORPHOMETRY OVER 2 & 5 YEARS - data from a treatment RCT on acute ACL injury R Frobell 1, W Wirth 2, LS Lohmander 1, M Hudelmaier 2, F Eckstein 2 1 Orthopedics, Clinical Sciences Lund, Lund University, Sweden 2 Paracelsus Medical University, Salzburg, Austria & Chondrometrics GmbH, Ainring, Germany
2 DISCLOSURES RF & SL - Nothing to declare FE, WW & MH Owner, co-owner / employee at Chondrometrics Gmbh, where image analysis was performed
3 ACL INJURY Incidence 80 / inhabitants & year (Frobell et al, SJMSS 2007) Treatment Early ACLR + rehabilitation Rehabilitation + delayed ACLR if needed Risk of OA 0-90%, but likely 50% in general No differences in treatment for ACL injury (Lohmander et al, AJSM 2007)
4 Symptomatic OA Radiographic OA MRI signs of OA Who comes first the hen or the egg?
5 MORPHOMETRY - CARTILAGE THICKNESS VirtualScopics Inc. Change in cartilage thickness over 2 years after acute ACL injury % change 10 KANON intense FUP 58 individuals 26 years 16 women 34 Early ACLR 24 Early Rehab 5 0 Central medial femur (cmf) Trochlea femur (TrF) Frobell et al, OAC Months
6 MORPHOMETRY - CARTILAGE THICKNESS VirtualScopics Inc. 1 year Cartilage swelling cmf Decreased AC in TrF Early ACLR may delay restitution Change in cartilage thickness over 2 years after acute ACL injury % change Central medial femur (cmf) Trochlea femur (TrF) Frobell et al, OAC Months
7 MORPHOMETRY - CARTILAGE THICKNESS VirtualScopics Inc. 2 years 34 Early ACLR 11 Delayed ACLR 16 Rehab alone Cartilage swelling cmf Decreased AC in TrF No difference between treatment groups Change in cartilage thickness over 2 years after acute ACL injury % change Central medial femur (cmf) Trochlea femur (TrF) Frobell, JBJS Months
8 OBJECTIVES Within a treatment RCT, we followed patients with an acute ACL injury to a previously uninjured knee: To investigate the association between patient relevant outcomes and changes in cartilage thickness (ThC) and total area of subchondral bone (tab) of the total femurotibial joint at 2 and 5 years To explore these associations in subgroups of treatment actually received
9 SAMPLE The KANON-trial, a randomized controlled trial comparing: Early surgical treatment strategy (n=62) Delayed surgery if needed strategy (n=59) Similar rehabilitation in both groups No differences in PRO or activity 2 years Frobell et al, NEJM 2010 No differences in PRO, activity level or 5 years Frobell et al, under revision July 2012
10 MATERIAL 107 / 121 patients of the RCT had complete set of MR images at: Baseline 2 years 5 years 1 / 107 was lost to clinical 5 years leaving 106 included in study All N=106 Women 26 (24%) Right knee (%) 59 (55%) Age, yrs (SD) 26 (5) BMI, kg/m2 (SD) 24.2 (3.0)
11 MATERIAL 107 / 121 patients of the RCT had complete set of MR images at: Baseline 2 years 5 years 1 / 107 was lost to clinical 5 years leaving 106 included in study All N=106 Early ACLR n=57 Delayed ACLR n=25 Rehab alone n=24 Women 26 (24%) 12 (21%) 8 (32%) 6 (25%) Right knee (%) 59 (55%) 29 (51%) 16 (64%) 13 (54%) Age, yrs (SD) 26 (5) 27 (5) 25 (5) 26 (5) BMI, kg/m2 (SD) 24.2 (3.0) 24.5 (3.2) 23.5 (2.0) 24.3 (3.1)
12 CLINICAL OUTCOME Knee injury & Osteoarthritis Outcome Score 0-100; worst to best Primary outcome of RCT KOOS 4 ; (Pain + Symptoms + Sports & Rec + QOL) / 4 All N=107 Early ACLR n=57 Delayed ACLR n=25 Rehab alone n=24 2 yrs 76.1 (20.3) 75.1 (20.7) 72.4 (20.7) 81.4 (18.5) Frobell et al 2010
13 CLINICAL OUTCOME Knee injury & Osteoarthritis Outcome Score 0-100; worst to best Primary outcome of RCT KOOS 4 ; (Pain + Symptoms + Sports & Rec + QOL) / 4 All N=107 Early ACLR n=57 Delayed ACLR n=25 Rehab alone n=24 KOOS 2 yrs 76.1 (20.3) 75.1 (20.7) 72.4 (20.7) 81.4 (18.5) KOOS 5 yrs 80.4 (16.6)* 79.7 (16.7) 79.0 (18.0) 83.5 (14.9) Frobell et al 2010 Frobell et al 2012 (under revision)
14 MR IMAGING 1.5T Philips Intera Sagittal FLASH sq 0.29mm IPR 1.5mm slice spacing Image BL (within 4 w of injury) 2 years 5 years
15 SEGMENTATION & COMPUTATION Segmentation of cartilages in femorotibial joint (FTJ): Medial and lateral tibia (MT/LT) Central 75% of the medial and lateral femoral condyle (cmf/clf) clf cmf clf LFTC MFTC LT LT MT FTJ = MFTC + LFTC
16 RESULTS ThCtab mm 2 years change 5 years change Total femurotibial joinf (FTJ) Medial compartment (MFTC) Lateral compartment (LFTC) Early ACLR Delayed ACLR Rehab alone Early ACLR Delayed ACLR Rehab alone Abstract #10, W Wirth, Friday 11:15 AM
17 RESULTS tab 2 years change Total femurotibial joinf (FTJ) Medial compartment (MFTC) Lateral compartment (LFTC) mm 2 5 years change Early ACLR Delayed ACLR Rehab alone Early ACLR Delayed ACLR Rehab alone
18 CARTILAGE THICKNESS - CLINICAL OUTCOME Cartilage 2 & 5 years No significant correlations between 2 & 5 years 2 yrs and ThCtab change over 2 & 5 years for FTJ MFTC LFTC Early ACLR Dealyed ACLR Rehab alone for entire sample or for any treatment group ThCtab change in FTJ over 2 years
19 SUBCHONDRAL BONE AREA CLINICAL OUTCOME Full analysis set 2 years tab medial compartment (MFTC) - KOOS 4 at 2 years (r= -0.21, p=0.03) 5 years tab in total joint (FTJ) - KOOS 4 at 2 years No correlations to KOOS 4 at 5 years (r= -0.20, p=0.04)
20 MFTC tab 2 YR CHANGE 2 YRS Full analysis set As treated analysis r= p= yrs r= p=0.01 Early ACLR Delayed ACLR Rehab alone Delayed ACLR: r= -0.18, p=0.39 Rehab alone: r= 0.19, p=0.37 tab change in MFTC over 2 years
21 FTJ tab 5 YR CHANGE 2 YRS Full analysis set As treated analysis 2 yrs r= -0.2 p=0.04 r= -0.3 p=0.03 Early ACLR Dealyed ACLR Rehab alone Dealyed ACLR: r= -0.19, p=0.35 Rehab alone: r= 0.13, p=0.56 tab change in FTJ over 5 years
22 SUBCHONDRAL BONE AREA CLINICAL OUTCOME As treated analysis (but not in full analysis set) 2 years Early ACLR tab in total joint (FTJ) - KOOS4 at 2 & 5 years Delayed ACLR & Rehab alone No relations found (r= -0.33, p=0.01 & r= -0.27, p=0.04)
23 LIMITATIONS KANON-trial is a treatment RCT not powered to find predictors Early ACLR group is twice as big as the other two groups 2 & 5 years may not be related to OA We do not know who will develop ROA or SxOA
24 CONCLUSION Increased tab, but not change in ThC, may be related to worse clinical outcome 2 years after ACL injury May be especially true for those treated with early ACLR - where increased tab of the total femurotibial joint was related to worse clinical outcome at both 2 & 5 years
25 THANK TO The KANON study group Felix Eckstein Martin Hudelmaier Wolfgang Wirth Chondrometrics Gmbh Founding sources: Swedish Research council Zoega foundation Gorthonfoundation Crafoord foundation Tore Nilsson foundation Region Skåne Swedish medical association CIF
CLINICAL OUTCOME & MORPHOMETRY OVER 2 & 5 YEARS - data from a treatment RCT on acute ACL injury
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